Health History Tips & Tricks: - ANSWERTJ Health Interview
Student: Hello! - ANSWERDiana Shadow: Hi. I'm Preceptor Diana. I will explain
the details of this assignment and your objectives, just as a preceptor would in
real life. Pay close attention to this information as it will help guide your exam. At
the end of this prebrief, you will answer a short question about the upcoming
assignment. During the simulation, you may return to these instructions at any
time by scrolling to the top of your transcript.
Student: What is the situation? - ANSWERDiana Shadow: Your patient is Tina
Jones:, a 28-year-old African American woman who has just been admitted to
Shadow General Hospital for a painful foot wound. Your role in this simulation is
that of a healthcare provider who will take Ms. Jones' health history, a key
component of her admission process.
Student: What are my objectives in this assessment? - ANSWERDiana Shadow:
A health history requires you to ask questions related to Ms. Jones' past and
present health, from her current foot wound to her pre-existing conditions. You
will also want to review Ms. Jones' systems, psychosocial history, and family
medical history. These assessments together will give you a comprehensive
picture of Ms. Jones' overall health. If you discover any disease states, ask about
symptoms and the patient's experiences of them. Your questioning should cover
a broad array of the symptoms' characteristics. Throughout the conversation, you
should educate and empathize with Ms. Jones when appropriate to increase her
health literacy and sense of well-being. Regardless of whether you have assessed
Ms. Jones previously, ask all questions that are necessary for obtaining a
complete health history. While you should communicate with patients using
accessible, everyday language, it is standard practice to use professional medical
terminology everywhere else, such as in documenting physical findings and
nursing notes. You may complete the exam activities in any order and move
between them as needed. After obtaining Ms. Jones' health history, you will
complete an information processing activity. You will identify and prioritize
diagnoses, then create a plan to address the identified diagnoses.
Student: What else will this exam involve? - ANSWERDiana Shadow: You will
complete nursing tasks to protect the patients safety, privacy, and health. You
can document your findings, including vital signs, in the Electronic Health
Record. This record provides necessary information for healthcare professionals
who will continue patient care. Besides Subjective Data Collection, and Education
and Empathy, there are activities within the simulation that provide valuable
practice for their real-world counterparts, but they are not automatically graded
by the simulation.
Student: How will I be evaluated? - ANSWERDiana Shadow: In this assignment,
you will be evaluated on your Subjective Data Collection, as well as your
Education and Empathy. Your success in Education and Empathy is based on
,whether you promptly respond after identifying a moment worthy of therapeutic
communication. The evaluation of your interview is dependent on how you word
your questions therapeutically and precisely and explore all relevant topics with
comprehensive breadth and depth. You will also be evaluated on your ability to
collect data and form nursing diagnoses in the information processing activity.
This assignment takes on average between 90 and 110 minutes. This exam may
take longer than in real life, because in this safe simulation, students of all
experience levels can take time to hone and review their skills. You can pause
and resume the assignment at any time; your work is always saved automatically.
Student: How does this assignment prepare me for the real world? -
ANSWERDiana Shadow: In this assessment, you will become familiarized with the
structure and content of a health history exam so that with real-life patients, you
can: º ask effective and comprehensive questions º obtain a thorough health
history º evaluate the patient's risk of disease, infection, injury, and complications
º educate and empathize º reflect on your experience and identify areas to
improve º identify and prioritize nursing diagnoses º and develop a plan to
address nursing diagnoses.
Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the
upcoming exam: Why is it important to obtain a patient's complete health
history? - ANSWERStudent: So that you understand if there are any problems
related to their chief complaint. Also, to help treat their current condition.
Diana Shadow: Time to begin. - ANSWER
Patient Exam - Vital Signs: - ANSWERHeight: 170 cm, Weight: 90 kg, BMI: 31,
Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90
mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%
Patient Exam - Interview: - ANSWER
Student: Hello, my name is Catlain, I am your nurse today. - ANSWERTina Jones:
Hey.
Student: Can you confirm your name? - ANSWERTina Jones: Tina Jones:.
Student: Why did you come in today? - ANSWERTina Jones: I got this scrape on
my foot a while ago, and it got really infected. It's killing me.
Student: What additional symptoms have you experienced? - ANSWERTina
Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like
hell... It's got all that going on.
,Student: Can you rate your current pain level on a scale of 0 to 10? -
ANSWERTina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave
me is helping a little bit.
Student: Please describe the pain. - ANSWERTina Jones: It's throbbing and like,
sharp if I try to put weight on it.
Student: How did you hurt your foot? - ANSWERTina Jones: I was changing a
light bulb, and I had to use our little stepstool to reach it. My foot slid off the
bottom step and it got all scraped up. I didn't realize how sharp the edge was!
Student: Has your foot been draining any liquids? - ANSWERTina Jones: Yeah,
there's definitely pus.
Student: What color was the pus? - ANSWERTina Jones: It's... white or maybe
off-white.
Student: How have you treated the wound? - ANSWERTina Jones: I've been
taking Advil for my foot for a few days.
Student: What did you do to treat your foot after your accident? - ANSWERTina
Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.
Student: How effective was the Neosporin? - ANSWERTina Jones: Well, I'm here,
so I guess it didn't do its job.
Student: Can you walk with your foot being injured? - ANSWERTina Jones: No, I
can't. I can't put any weight on it without like, shooting pain.
Student: What preexisting medical conditions do you have? - ANSWERTina
Jones: I mean, I have asthma and diabetes, but right I now I just care about my
foot!
Student: I understand your foot hurts, but I need to know this information to
make sure I take care of the problem correctly. - ANSWERTina Jones: Thanks.
Student: When were you diagnosed with diabetes? - ANSWERTina Jones: I was
diagnosed when I was 24.
Student: What do you do to manage your asthma? - ANSWERTina Jones: I try to
avoid things that give me breathing problems, but when my asthma starts to act
up, I just use my inhaler.
Student: What medications did you take for your diabetes? - ANSWERTina
Jones: It was metformin.
, Student: Do you currently take medicine for your diabetes? - ANSWERTina
Jones: No, I don't take anything for my diabetes anymore.
Student: What made you stop taking medication for your diabetes? -
ANSWERTina Jones: I guess I just got sick of feeling sick and gassy all the time,
and it was overwhelming, remembering to take pills and check my sugar. I feel a
lot better now that I'm just eating healthier than I did when I was taking the pills.
Student: Do you monitor your blood glucose? - ANSWERTina Jones: I have a
monitor at home, but to be honest I don't really use it that often.
Student: How frequently do you urinate? - ANSWERTina Jones: I don't know.
Every hour or two when I'm awake?
Student: What is your current diet? - ANSWERTina Jones: It's pretty good, I
think. I'm not a huge health nut or anything.
Student: Have you had any change in appetite? - ANSWERTina Jones: Yeah,
lately I've definitely been much hungrier than usual.
Student: Has your weight changed? - ANSWERTina Jones: Yeah, I've lost some
weight recently.
Student: Do you know why you lost weight? - ANSWERTina Jones: I don't know
what caused it, I just lost weight.
Student: How often do you have asthma exacerbations? - ANSWERTina Jones: I
haven't had a full attack in years. But my breathing definitely acts up. . .not
always. Max twice a week.
Student: What asthma symptoms have you experienced? - ANSWERTina Jones:
My chest and throat get tight, and I start to wheeze. It feels like I can't take in air,
like I can't get enough air into my lungs.
Student: How many puffs do you take when using your asthma inhaler? -
ANSWERTina Jones: I usually use two puffs from my inhaler, but sometimes I
need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]
Student: What are some things that trigger your asthma? - ANSWERTina Jones:
Being around cats is the worst, but dust and running up stairs can make my
breathing bad, too.
Student: What allergies do you have? - ANSWERTina Jones: I'm allergic to cats.
Student: When did you realize you were allergic to cats? - ANSWERTina Jones:
For as long as I've been around.
